How to Stop Overdose Deaths in New York

April brought two big developments in the battle to combat heroin and opioid drug overdose: the New York Attorney General announced a program to use $5 million to equip police with the overdose antidote naloxone. The same day, a new naloxone auto-injector device, called Evzio, was approved by the U.S. Food and Drug Administration. We sat down with Matt Curtis, the policy director of VOCAL New York, to discuss what these developments mean.

New York’s Attorney General is proposing to use $5 million to equip every state and local police officer with the overdose antidote naloxone. Is this a breakthrough for overdose prevention?

Yes and no. In some parts of the state police officers are frequently first on the scene at an overdose, and by equipping them with naloxone they will now have the ability to save lives. But this is not the whole answer.

Despite New York’s 911 Good Samaritan law, not everyone will call 911 for help during an overdose. There’s also no reason to make people at the scene of an overdose wait for the police or an ambulance to arrive when they could be responding themselves. Study after study has shown that bystanders and non-medical professionals are fully capable of providing appropriate first aid, including administering naloxone. And during an overdose, every second counts.

After nearly 20 years of community-based overdose education and naloxone distribution programs in the United States we know that people who use drugs, their friends, and their family members always have and always will be the best first responders during an overdose. What’s missing in most of the stories about Attorney General Schneiderman’s announcement is any mention of this work in New York State. We’re now looking to engage with the Attorney General’s office to make sure that law enforcement is able to learn from the dozens of programs around the state that have paved the way.

While the new law enforcement program is a positive step, the resources being dedicated to it are in stark contrast to what’s on offer to community programs that are desperately needed, and are chronically underfunded. In 2013, total public funding from the New York state and city governments for these programs was well under $1 million.

The money mostly went to buy naloxone kits, but also to support basic program infrastructure and pay a handful of prescribers. Though it’s difficult to come to an exact figure, the total national investment for community naloxone programs is likely less than what New York will dedicate to this police program alone.

It’s important to acknowledge that asset forfeiture money can only be spent on law enforcement, so this is certainly not a matter of the Attorney General making a bad decision. But we need our state legislature and the NYC Council to appropriately dedicate funds to naloxone and overdose prevention that are commensurate with the scale of the overdose epidemic.

The other big news this week was that the FDA approved a new naloxone product—an auto-injector called Evzio. Will this new product make naloxone more accessible for those who need it most—people who use opioids?

The last thing advocates have been asking the federal government for is an expensive, prescription-based naloxone delivery device. What we need is for federal agencies like the National Institutes on Drug Abuse and the FDA to incentivize development of low-cost, over-the-counter naloxone—a very feasible goal.

Evzio on its own looks like a great product, but it has at least three major downsides in the context of community-based overdose prevention programs:

Though a price has not yet been announced, if it’s in line with other auto-injector devices—like epinephrine injectors for allergic reactions—then it is likely to cost in the hundreds of dollars a device.

And, while insurance plans may reimburse for it, this price would put the device out of reach of community-based programs that have limited budgets, and that routinely distribute multiple doses to people after they are trained to use it.

A high price for Evzio may encourage the other naloxone producers in the U.S. to increase their prices, as well. In fact, one of the main producers, Hospira, recently announced that they're raising the price of their product. There will be major consequences for community programs if this marks the start of significant price increases.

What are the top priorities for reducing opioid overdose in New York State?

We recently released a briefing paper describing policy changes that we think are needed to end New York’s overdose epidemic. One of those changes is reflected in legislation introduced earlier this year that would allow standing order naloxone prescribing—enabling staff at harm reduction programs and other agencies to distribute naloxone directly without a doctor or other prescriber present. The legislation would also allow pharmacists to dispense naloxone to eligible people without a prescription. The bill unanimously passed our state Senate a couple weeks ago, and we expect an Assembly vote later this month.

Beyond naloxone, we need to improve access to drug treatment, especially opioid substitution therapy with methadone or buprenorphine. New York City would benefit tremendously from supervised injection facilities (SIFs) like Canada’s very successful InSite program. We have a huge population of homeless or unstably housed injectors here, and SIFs have been rigorously studied and shown to reduce not only overdose, but also HIV and viral hepatitis transmission, and public disorder.

And beyond the level of public health interventions, the best thing we can do to stop overdose and other drug related harms is to end the war on drugs. Our country has put a trillion dollars into the drug war over the last four decades, incarcerated tens of millions of people, and it’s been an utter disaster. We take this especially personally in New York, where the Rockefeller drug laws incubated many of the worst policies in the early 1970s.

That’s our bigger goal here. No one should be getting arrested for simple drug possession, and no one should have a judge making medical decisions about drug treatment for them. So, to answer your question: Evidence-based public health strategies, alongside a basic approach that values dignity and compassion rather than punishment, are what will win the battle against overdose deaths.

The problem of drug overdose is the most challenging world disaster. However, there should be laws amendment to stop and prevent people from drug overdose. Such laws should be in line with heavy punishments for those who illigally sell or misuse the drugs.

Yes, in the tactical fight against overdose deaths. But as a way to prevent overdoses in the first place, "Follow Switzerland's Lead", the headline of my letter printed in the Tampa Tribune recently... as follows:

Re: May 21, editorial, "Florida's next drug problem: heroin"

FOLLOW SWITZERLAND'S LEAD

Since much heroin is by taken by injection, we also will likely see increases in hepatitis C and HIV infection. In the mid 1990s, these diseases drove the Swiss to try something radical, and it worked. The Swiss now offer treatment-on-demand. Of an estimated 22,000 to 24,000 addicts, 16,500 are in treatment, primarily with methadone maintenance at conventional clinics. The Swiss treat about 1,300 hard-core addicts with maintenance doses of herA-oin in 23 special clinics operating in cities and two prisons.

The Swiss are seeing lower rates of crime, death and disease. Most important, the age of hard-core addicts is climbing, indicating that fewer young people are becoming addicted. The program has been adopted by Germany, Belgium and Denmark. The Times suggests allowing EMTs to carry and administer naloxone to prevent overdose deaths, and greater treatment options for addicts instead of simply punishment and incarceration. Yes, but also look beyond the United States for solutions.

While I'm happy to see the antidote becoming available, I believe that overdoses are inevitable until possession is no longer illegal. In fact, I would go further than policies like that of the Dutch and advocate for treating drugs like other controlled substances so their manufacture can be standardized and thus be clearly labelled.

We have saved hundreds of lives by delivering free Naloxone at harm reduction programs in 2013 in Georgia Republic. It was especially needed medicine while the leading drug in country drug scene was Dezomorphine (home made Opioid, so called Crocodile). Simultanously we were providing targeted education of PWID about Naloxone. Yes it really worked hard, especially in countries where drug consumption is illegal, where Goog Samaritan Laws does not work and people are frighten to call ambulance... But now we are facing another difficulties regarding overdone with mixed drugs (among them stimulants, smoked Bios and other, that are bought by internet and their basic ingredients are not recognized yet). We are unable to save lives in all overdose cases unfortunately. There should exist other way to prevent overdose with mixed and indefinable drugs....

I experience being addicted to drugs for years, a couple of times being revived from an overdose. There were ways to revive a person, a salt shot, using ice and walking person around. I share my degradation in memoir Lust of a Dope Fiend. And share recovery in a self help book Redeem Yourself.

Interventions such as naloxone are critically important as life-saving measures for those overdosing from drugs. What becomes imperative is the community education around drugs such as naloxone and Good Samaritan laws so that the broader community knows what they can do. In addition to these interventions though, what becomes equally important is PREVENTION. Prevention is essential to dealing with the AODA issues our country faces, especially with our young people.

"Is it enough?" No, as Herman Brood, the late Dutch artist, who loved amfetamine and alcohol, sang, "Never Enough!" Naloxone is a gift from pharma heaven and the grass roots effort to push for this life saving intervention has gained great momentum. However, more needs to be done - e.g. promote modes of administration that are less prone to overdose. Likewise, opioids are not the only source of overdose. In the EU there are reportedly extremely high purity ecstasy tablets circulating in the black market, which have been associated with fatalities. With the advent of NPS (New Psychoactive Substances, legal highs, research chemicals, etc.), global drug markets are rapidly changing and so will the related harms, including overdose.

In Tanzania the availability of Naloxone is extremely limited; only a few government hospitals and some private institutions have it. It would be fantastic if people who inject heroin could carry it on them to save their peers in case of overdose. It would save so many lives. But indeed, it would not be enough. We need to scale up harm reduction interventions, so more (potential) injectors can be trained on how to prevent, recognise and manage overdose. Besides we need more drug treatment facilities for those who want to say goodbye to heroin. And of course we need drug policies that do not criminalise people who use drugs and a society that doesn't stigmatise them.

Thank you for this informative article, your paragraph before last is the answer to the problem: "And beyond the level of public health interventions, the best thing we can do to stop overdose and other drug related harms is to end the war on drugs. Our country has put a trillion dollars into the drug war over the last four decades, incarcerated tens of millions of people, and it’s been an utter disaster. We take this especially personally in New York, where the Rockefeller drug laws incubated many of the worst policies in the early 1970s."

War on Drugs is the problem, solution is decriminalization of opium similar to marijuana, see drugpolicy.org and berkeleywellness.com june 2014 edition by UC Berkeley. When society outlaws a plant that is produced by God/nature, it inevitably must approve big, greedy pharmaceutical and prisons industries; to revert, small steps of antioverdose drugs will benefit a few; however, normal heathcare and education with treatment of opium as alcohol, tobacco and now marijuana is the answer.